Self-rated health as a proxy for frailty in older adults at emergency departments

Ebony Lewis1, Dr Magnolia Cardona-Morrell1, Dr Hatem  Alkhouri2, Professor Ken Hillman1,3

1The Simpson Centre for Health Services Research SWS Clinical School and the Ingham Institute for Applied Medical Research. University Of New South Wales , Liverpool, Australia, 2Agency for Clinical Innovation, Emergency Care Institute , Sydney , Australia, 3Liverpool Hospital Intensive Care Unit , Liverpool, Australia

Background: Despite the availability of screening tools to measure frailty, in the busy emergency department environment staff are restricted to measure objectively the parameters of existing tools. Therefore a rapid, practical instrument is required. Aims: To determine if self-rated health could be used as a proxy for frailty on admission and as a high-risk flag for people who will need community support post hospital discharge. Methods: Nurse-measured frailty scores using The Clinical Frailty Scale on consecutive older patients from a cohort 65+years admitted via emergency departments during business hours to four large Australian teaching hospitals. Frailty assessment repeated over the telephone at around three months post admission. Logistic regression used to examine associations controlling for sociodemographic and clinical parameters. Results: Within the cohort, 889 (88%) of patients (51.4% female) with mean and median age 80 years had data at baseline and follow-up. Preliminary results showed that a FairPoor self-rated health was significantly associated with baseline frailty in univariate analysis (OR 3.82, 95%CI 2.89-5.06). After adjusting for age, sex and comorbidities, FairPoor self-rated health had a strong and statistically significant association with frailty (OR 4.02, 95%CI 2.92-5.52 p<0.001). Self-rated health on admission was also an independent predictor of needing community services at follow–up (OR 1.79, 95%CI 1.33-2.42 p<0.001). Conclusion: FairPoor self-rated health on admission may be a useful proxy for frailty in the emergency department environment where comprehensive frailty instruments cannot be fully administered. It could also guide clinicians to anticipate the need for community services at discharge.


Biography:

Has come from a background of Emergency Nursing and in 2014 completed a Master of International Public Health (MIPH) at the University of New South Wales.Her main interests are End-Of-Life Care, International Health and Non-Communicable Disease Prevention.

Substance misuse and the involuntarily presentation to the Emergency Department

James Hughes1, Maureen Sheehan2, Jill Evans3

1Princess Alexandra Hospital, Brisbane, Australia, 2Drug and Alcohol Brief Intervention Team, Logan Hospital, Medowbrook, Australia, 3Metro South Addiction and Mental Health Services, Brisbane, Australia

Background: Alcohol and other drug (AOD) use are common in our society. The use of these substances flow throughout all areas of healthcare and is especially prevalent in patients presenting to the emergency department with signs of mental illness. At the extreme end of these presentations, patients present involuntarily with either police or ambulance officers via an Emergency Examination Order (EEO).

Aim: The aim of this study was to identify and describe the population presenting to the ED involuntarily with and without substance misuse as a precipitating factor and explain the differences in care between these two populations.

Methods: Quantitative descriptive analysis was used to describe this population between April and June 2015.

Results:  During the study period, there were 317 patients reported to be on an EEO presented, which represented 2.32% of total presentations for this time. In patients presenting to one large inner city emergency department involuntarily, 30% had alcohol or other drug misuse as a precipitating factor. Patients who involuntarily presented with alcohol and other misuse stay longer in the emergency department than others that do not have alcohol or other drug misuse. These patients frequently represent, with over 50% representing at 90 days however this was not associated with alcohol or other drug misuse. Almost all patients who present involuntarily are discharged home post review by a mental health team. Significant improvements in care can be made in this population if the opportunistic treatment of both mental illness and AOD misuse is completed in the emergency department.


Biography:

Mr Hughes has worked in some of the busiest emergency departments in Queensland. He currently is a Clinical Nurse Consultant at the Princess Alexandra Hospital in Brisbane and is completing his PhD in factors that influence pain care in the emergency department.

Rates and features of methamphetamine-related presentations to emergency departments: An integrative literature review

Rikki Jones1, Professor Kim  Usher1, Dr Cindy Woods1

1University of New England, Armidale, Australia

Background: Methamphetamine distribution and use has rapidly spread across Australia. As a result, the number of methamphetamine-related presentations to emergency departments (EDs) has also increased. In this context, it is timely to review the rate and features of methamphetamine-related presentations to facilitate the allocation of services, staff and resources to understand the impact of methamphetamine presentations on ED’s.

Aim: To present and review the available evidence related to the features and rates of methamphetamine-related presentations to EDs.

Method: A search was conducted of CINAHL, CINCH, EBSCO, ProQuest- health and medicine, and PubMed; databases using a combination of the search terms: “emergency department”; “methamphetamine-related”; “crystal meth or crystal methamphetamine”; “presentations”; “accident and emergency”; and, “drug-related”. Articles were measure against inclusion and exclusion criteria and subjected to quality appraisal.

Results: 27 articles were identified, 18 were excluded leaving 9 articles included in the final review. Methamphetamine accounted for less than 2.3% of all ED presentations. The majority of methamphetamine users presenting to EDs were Caucasian males, with a mean age 30-37. Methamphetamine-related presentations ED presentations were more likely to present with trauma, psychosis, and be placed on 24-hour psychiatric hold. Methamphetamine-related presentations were more likely to present with agitated, aggressive and homicidal behaviour and present to ED out of hours and accompanied by police compared with other ED presentations.

Conclusion: Several important themes were highlighted in this review that have an impact on ED services, resources and staff. Understanding the rate and patterns of methamphetamine-related presentations can help to provide evidence for health promotion and policy development in ED.


Biography:

Rikki Jones is an experienced nurse who has worked in EDs, cheaters, and community health across rural and remote settings. She has worked in an educators role in a rural remote area before commencing in an academic position in the School of Health at UNE. She is currently enrolled in a MPhil by research at UNE and the focus of the study is ‘rates and patterns of methamphetamine-realted presentations to ED in QLD between 2010-2015’.

Patient medication literacy and safety in an Emergency Department

Wayne Varndell1,2, Kylie Lovato1, Alison Jeffers1, Nadya Marquez-Hunt1, Rebecca Carroll1

1Prince Of Wales Hospital, Randwick, Australia, 2University of Technology Sydney, Ultimo, Australia

Background: Medications play a primary role in the management of most illness and injuries. Over two-thirds of patients discharged from the emergency department (ED) are provided with medication.1  Conversely medicines also account for an increasing number of ED presentations, revisits and preventable hospital admissions due to adverse drug events, which have been linked to low levels of patient medication literacy.2, 3  Medication literacy refers to the degree to which individuals are able to obtain, process, comprehend and act upon information to safely interpret and administer medication.4 Yet to date, it has not been examined within Australia, or within the ED setting.  The purpose of this study is to measure medication literacy levels of patients being discharged from ED, and explore their practices in the use and storage of prescribed medication.

Method: A prospective, descriptive study based upon a convenience sample (n=100) of adult (>16 years) patients. Patient medication use and storage practices will be evaluated by questionnaire, medication literacy will be assessed using the MedLitRx.4

Results: We will report the results of the above study; highlighting trends and emerging issues that may be useful in practice, education and future research to improve patient safety in the use and management of prescribed medication.

Conclusions:  Patients presenting to ED are frequently discharged with medication, and are often reliant upon emergency nurses for information about the use of medication prescribed or package labelling.  Low levels of medication literacy are associated with poor patient outcomes and negative impact upon ED resources, which are potentially avoidable.


Biography:

Kylie Lovato is Nurse Educator at Prince of Wales Hospital ED, and is an active clinician, educator and researcher in emergency healthcare and nursing.

Nursing handover of vital signs at the transition of care from the emergency department to the inpatient ward: An integrative review

Rachel Cross1,2, Professor Judy  Currey2, Professor Julie Considine2,3

1La Trobe University, Melbourne, Australia, 2Deakin University, Burwood , Australia, 3Eastern Health, Box Hill , Australia

Aim: To examine current handover of vital signs during patient transfer from the emergency department (ED) to the inpatient ward.

Background: Clinical handover is an international healthcare priority. The transition of care from the ED to the inpatient ward is informed by nursing handover. Vital sign abnormalities in the ED are predictive of clinical deterioration following hospital admission. Understanding the inclusion of vital sign content in clinical handover is important for patient safety.

Methods: An integrative design was used. A search of electronic databases was undertaken using MEDLINE, CINAHL, EMBASE, COCHRANE, Web of Science, SCOPUS. Identified records were also screened to elicit further studies for inclusion. A comprehensive peer review screening process was performed. Studies were included that described the issues of handover, vital signs, emergency department, transition of care and ward.

Results: Four studies were included in the final review. All were specific for emergency medicine. None were specific for emergency nursing handover. Identified studies were evaluated to identify similarities and differences; two themes emerged. Vital signs were incorporated into clinical handover at varying levels and were perceived to be an important inclusion. Vital signs were also perceived to be indicators for patient safety, and risk factors for future clinical deterioration.

Conclusion: Vital signs were included at varying levels in clinical handover. No studies were specific for ED to ward nursing handover despite nurses having a key role in the measurement and interpretation of vital signs and escalation of care. Deficiencies in vital sign content were perceived to be risk factors for patient adverse events following hospital admission. The quality of vital sign information in clinical handover may be important for accurate decision making.

Implications: Vital signs are an important component of clinical handover and are perceived to be indicators for patient safety and risk for future clinical deterioration.


Biography:

Rachel Cross is a PhD candidate examining the transition of patient care from the emergency department to the inpatient ward. Her PhD is focused on clinical deterioration and clinical handover. Rachel works as a Lecturer and an emergency nurse in a major metropolitan hospital in Melbourne Victoria.

Missed opportunities to introduce non-acute care pathways for elderly patients with palliative care needs

Dr Magnolia  Cardona-Morrell1, Ebony Lewis1, Dr Robin Turner2, Dr Hatem Alkhouri3, Dr Stephen  Asha4, Dr John  Mackenzie5, Dr Anna Holdgate6, Dr Sam Suri7, Dr Luis  Winoto8, Dr  Sally  McCarthy3,5, Professor Ken Hillman1,9

1The Simpson Centre for Health Services Research. The University Of New South Wales , Liverpool, Australia, 2School of Public Health and Community Medicine. The University of New South Wales, Sydney , Australia, 3Emergency Care Institute , Chatswood, Australia, 4St George Hospital Emergency Department , Kogarah, Australia, 5Prince of Wales Hospital Emergency Department, Randwick, Australia, 6Liverpool Hospital Emergency Department, Liverpool, Australia, 7Campbelltown Hospital Intensive Care Unit , Campbelltown , Australia, 8Sutherland Hospital Emergency Department , Sutherland , Australia, 9Liverpool Hospital Intensive Care Unit, Liverpool, Australia

Background

Most chronically ill older people want to die at home but many still seek hospital services in their last year of life.

Aims

To typify elderly patients who may benefit from earlier transition to palliative care rather than long hospitalisation in acute care.

Methods

Prospective  analysis of cohort data for 65+ year-olds admitted to hospital via the Emergency Department in 2015-2016.

Results

Of the 1,143 hospitalized elderly in the cohort, 48% were managed by four specialties: Geriatrics, Cardiology, Respiratory and Neurology. Only 5 patients (0.44%) had advance care directives. Ten percent died within six months of admission, 60% during the acute hospital stay. The following flags could have indicated time for transition to palliative care: relative to the survivors, the deceased were significantly more likely to: be older than 80 years (mean 82.5 vs 79.6, p=0.0003); be residents of nursing homes or in supported accommodation (20% vs. 6% of survivors, p<0.0001); suffer from at least two chronic illnesses (28% vs. 14%), p<0.0001); have been admitted to hospital at least once in the past year (73% vs. 57%, p=0.0012); have a do-not-resuscitate order (18% vs.3%, p<0.0001); and have length of stay longer than a week (mean LOS 9.6 days vs. 6.1, p=0.0163).

Conclusion

Communication of imminent death is complex and difficult, particularly in busy emergency departments. However, being alert to the presence of flags for imminent death could have resulted in shorter length of stay, earlier referrals to palliative care and less suffering. Further research is needed to clarify the reasons for underuse of palliative care services in the Australian context.


Biography:

Comes from a background of Emergency Nursing and in 2014 completed a Master of International Public Health (MIPH) at the University of New South Wales.Her main interests are End-Of-Life Care, International Health and Non-Communicable Disease Prevention.

Improving the patient experience: Working in collaboration

Amy Goeman1, Dr Rachel Rosler2

1Monash Health , Dandenong, Australia, 2Monash Health, Dandenong, Australia

Background

The Australian Charter of Healthcare Rights states that patients and other people using the Australian health system have the right to the provision of high quality and safe care. The Charter also states that a genuine partnership between patients, consumers and providers working together is needed to achieve this outcome [1]. Additionally, research from the MAYO clinic demonstrates that patients who have a less than optimal experience have a slower recovery [2].  The Emergency Department (ED) is pivotal to providing acute care services, however, overcrowding, long waits and uncomfortable conditions can lead to a less than ideal experience for patients that attend. We are undertaking a study to ascertain the experience of patients admitted to the acute assessment unit from the Dandenong ED and garner their thoughts about what may have improved their experience. We also seek the views of staff working in the ED setting about their thoughts on improving the experience for patients. While the overall aim of our study is to improve the patient experience we also aim to break down communication barriers between ED staff and inpatient units and to improve inter-professional collaboration between ED medical and ED nursing by role modelling and providing feedback to ED staff in a timely manner. The ED Nurse Unit Manager and the ED Medical Director visit patients together who meet inclusion criteria twice a week to discuss their ED experience.

References

  1. Australian Commission on Safety and Quality in Health Care. Review of patient experience and satisfaction surveys conducted within public and private hospitals in Australia. May 2012.
  2. Pruthi S, VerNess C, Stevens S. Service Recovery in Healthcare: movement from reactive to proactive. The Beryl Institute Patient Experience Conference 2015.

Biography:

Amy Goeman is an Acting Nurse Unit Manager at Dandenong Emergency Department. After 9 years of emergency nursing practice and completing a Masters in Nursing degree at Monash University, Amy has become passionate about making a broader contribution to public health and nursing.

Amy has trekked through the Annapurna’s in Nepal with TrekMedic providing free medical care to locals and inside of a prison in Kathmandu.

Amy has contributed to research as a research nurse in multiple studies for both Monash University and Deakin University and is currently undertaking a Masters in Public Health at the University of Melbourne

From there to here and here to there. Nurses are active everywhere!

Stephanie Chappel1, Professor Julie Considine2,3, Associate Professor Brad Aisbett1, Dr Nicola Ridgers1

1Deakin University, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, Geelong, Australia, 2Deakin University, School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Geelong, Australia, 3Centre for Quality and Patient Safety Research – Eastern Health Partnership, Box Hill, Australia

INTRODUCTION

It has been suggested that nurses need interventions to increase their physical activity (PA) levels, yet these recommendations are based on their leisure-time PA. Emergency nursing is physically demanding, and it is possible that they accumulate the majority of their PA at work. Before making recommendations about nurses’ occupational PA levels, a better understanding of nurses total PA (occupational and leisure) is needed. Limited research exists relating to nurses’ occupational PA levels, but current evidence suggests that the majority of shifts are spent in light-intensity activity (mainly standing and slow walking) interspersed with moderate-intensity nursing tasks. Consequently, it appears that nurses meet the PA guidelines through work activity alone. However, it is known how nurses accumulate their occupational PA. The aim of this study is to understand emergency nurses’ occupational PA levels and the effect of leisure-time activity and shift work on occupational PA.

METHODS

Nurses will be recruited through three hospitals with emergency departments. Eligible participants are emergency nurses working a combination of early, late and/or night shifts. Nurses with a current injury or in their 3rd trimester of pregnancy will be excluded. Emergency nurses will be asked to wear an ActiGraph monitor on their hip during work and leisure-time. This monitor measures the intensity of the activity they engage in across the day (e.g., sedentary, light, moderate and vigorous). Nurses will also be asked to wear a new device on their thigh (activPAL) which measures sitting, standing and stepping time. Daily work and sleep diaries will also be completed. Given these data are time stamped, occupational and leisure-time PA patterns can be explored in detail. Analyses will examine the effects of PA accumulated in one shift on the next, and the influence of leisure-time on occupational PA and vice versa.

RESULTS

Preliminary results will be presented.


Biography:

Ms Stephanie E. Chappel is a current PhD candidate in the Institute for Physical Activity and Nutrition (IPAN) at Deakin University. She is currently in her second year of candidature. Stephanie has completed her Bachelor of Exercise and Sports Science (Honours) in 2015 at Deakin University on ‘Firefighters Physical Activity across Multiple Shifts of Planned Burn Work’, which was published in 2016.  She has also recently published a review  ‘Nurses’ occupational physical activity levels: A systematic review’ and a commentary piece ‘Putting the ‘Physical’ Back into Nursing: Recognising Nursing as a Physically Demanding Occupation’. Stephanie’s PhD thesis is focusing on nurses’ on-shift physical activity levels, with a particular focus on emergency nursing.

Emergency triage documentation: An examination of the content and patterns of content

Michelle Jory1, James Hughes2, Rob Eley2, Anthony Tuckett1

1The University Of Queensland, Brisbane , Australia, 2Princess Alexandra Hostpital, Brisbane, Australia

Background: The accurate triaging of patients who present to the Emergency Department is vital for ensuring patients are seen according to a priority attributable to their presenting symptoms. In Australia, nurses assign patients a triage score from 1 to 5 determining time-to-treatment, accompanied by a free-text description of their presenting condition, guided by the ACEM guidelines which are replicated in the Emergency Triage Education Kit. Consistency is required when recording free-text descriptions to ensure safe and quality care.

Methods: A qualitative content analysis of 250 randomised free-text descriptions from a Public Metropolitan Adult Tertiary Referral Hospital, Emergency Department electronic medical record, between November 2015 and November 2016.

Results: Variation in both frequency and order of citation of documented pieces of triage information was evident among the 250 free-text descriptions. The documented information differed among certain presenting problems such as pain presentations and physical injury presentations. Pain presentations were the most commonly documented presenting problem however, documentation of the onset (24.4%), location (65.9%) and description (54.9%) of pain occurred in less than three-quarters of all pain presentations. Documentation of the onset, location and description of pain is essential in providing safe and quality nursing care and in minimising the risk of oligoanalgesia.

Conclusion: Findings indicated different levels of compliance and significant variation in the content and patterns of content of free-text documentation. These findings provide opportunities to create clinical change through recommendations of guideline revisions for both the ACEM and ETEK documents, and renewed triage education and training practices in Australian emergency departments. Further research in triage documentation is necessary in providing a stronger evidence base to support the results from this study.


Biography:

Michelle Jory is a third year Bachelor of Nursing student from the University of Queensland. Michelle has a particular interest in emergency nursing, emergency care, and emergency triage. Michelle is the first undergraduate nurse to have completed a Summer Research Scholarship Program at the Princess Alexandra Emergency Department and since completion of the eight-week scholarship, has shown an eagerness to complete a research higher degree in the near future.

ED nurse recognition of sepsis is critical to early administration of antibiotics in patients with sepsis to reduce mortality: A systematic review and meta-analysis

Dr Amy Johnston1, Dr Joon Park2, Professor Suhail  Doi3, Vicki  Sharman4, Justin  Clark5, Jemma  Robinson4, Professor Julia Crilly1

1Dept Emergency Medicine, Gold Coast Health and Menzies Health Institute Qld  , Southport, Australia, 2Dept Emergency Medicine, Gold Coast Health and The Prince Charles Hospital , Chermside, Australia, 3Research School of Population Health, Australian National University and College of Medicine, Qatar University, Doha, Qatar, Canberra, , Australia, 4Pharmacy Dept and Dept Emergency Medicine, Gold Coast University Hospital, Southport, Australia, 5Centre for Research in Evidence-Based Practice, Bond University , Southport, Australia

Background:  Sepsis is a time sensitive illness. Emergency department (ED) clinicians play an important role in the early recognition and management of sepsis. Part of sepsis management includes initiating broad spectrum antibiotics, ideally within the first hour of diagnosis. Despite various guidelines the evidence underpinning such recommendations remains limited. Understanding the extent to which early administration of antibiotics occurs in the ED and the impact this has on patient mortality warranted this review.

Purpose:  The goal of this review was to synthesize (pool) existing evidence regarding mortality for patients who present to the emergency department and are administered antibiotics immediately (≤1 hour) or later (>1 hour), and are diagnosed with sepsis.

Methods:  A search of databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL, using the MeSH descriptors “sepsis,” “systemic inflammatory response syndrome,” “mortality,” “emergency,” and “antibiotics,” was undertaken to identify studies that reported ‘time to antibiotic administration’ and mortality in patients with sepsis. Study data were extracted using a tailored data extraction form and all studies were evaluated for methodologic quality. From an initial pool of 582 possibly relevant studies, 10 studies had quantitative data for an overall meta-analysis. Three different statistical models were used to perform the meta-analysis.

Findings:    The pooled results suggest a significant, 33%, reduction in mortality odds for immediate (≤ 1 hour) compared with later (>1 hour) antibiotic administration (OR, 0.67 [95%CI, 0.59– 0.75]) in patients with sepsis.

Implications:   Immediate antibiotic administration (≤1 hour) seemed to reduce patient mortality, helping to provide an evidence-base for ED recommendations. This timeframe requires that informed and aware nurses contribute to early, comprehensive, sepsis management within the ED. ED nurses maintain their central role as a critical components in early detection and management of patients with suspected sepsis.


Biography:

Amy Johnston is a conjoint research fellow in Emergency Care, based between Gold Coast Health and Menzies Health Institute Queensland/School of Nursing and Midwifery Griffith University. She is deeply committed to bringing research skills and outcomes to emergency staff and consumers. She is a widely published and cited academic and registered nurse with experience in a range of research techniques.

12